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Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department
  1. Edir S Abid1,
  2. Kelsey A Miller1,2,
  3. Michael C Monuteaux1,2,
  4. Joshua Nagler1,2
  1. 1Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  2. 2Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Joshua Nagler, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; joshua.nagler{at}childrens.harvard.edu

Abstract

Background Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting.

Objective We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations.

Design and methods We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors.

Results During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy.

Conclusion Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.

  • paediatrics
  • paediatric emergency medicine
  • airway

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All included data were abstracted from an internal quality assurance database and the electronic health record, and are deidentified for the purpose of analyses and reporting.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All included data were abstracted from an internal quality assurance database and the electronic health record, and are deidentified for the purpose of analyses and reporting.

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Footnotes

  • Handling editor Gene Yong-Kwang Ong

  • Twitter @millerkelseyann

  • Contributors JN conceived the study. ESA and JN designed the study. ESA, KAM and JN abstracted data, MCM provided statistical advice on study design and analysed the data. ESA, KAM, and JN drafted the manuscript, and all authors contributed substantially to its revision. Each author has seen and approved the final version of the manuscript and takes responsibility for the submission. JN is responsible for the overall content as guarantor and accepts full responsibility for the finished work product, the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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